CommercialCoverageHigh impact
Novel Injection Methods (CPB 0777, reviewed 2025-12-02)
Aetna·Ophthalmology, Pharmacy·Pharmacy
Effective date
Dec 2, 2025
We identified it
Aug 17, 2026
Summary
Aetna's new Clinical Policy Bulletin 0777 establishes coverage criteria for novel ophthalmic injection methods. Specifically, supra-choroidal injection of triamcinolone acetonide (Xipere) for uveitic macular edema is now covered when criteria in CPB 1000 are met; sub-retinal rtPA injection for sub-macular hemorrhage is covered; but all other supra-choroidal agents and the Mercator Bullfrog micro-infusion device remain experimental/unproven and are not covered. Billing teams must immediately implement coverage rules to avoid claim denials for non-approved injection methods.
Action Required
Immediately (effective 2025-12-02): Billing team must update claim edit rules in billing software to enforce coverage restrictions per CPB 0777. (1) CPT 67516 (supra-choroidal injection) is COVERED ONLY with HCPCS J3299 (Xipere triamcinolone) AND ICD-10 H35.81 (retinal edema from uveitis) when medical necessity criteria in CPB 1000 are documented—require prior authorization and verification that CPB 1000 criteria are met before processing. (2) CPT 67516 and CPT 0699T are NOT COVERED for any other supra-choroidal agent deliveries—implement system rules to deny these code combinations automatically. (3) CPT 0810T (sub-retinal rtPA injection) is COVERED when ICD-10 code H35.60, H35.61, H35.62, or H35.63 (sub-macular hemorrhage) is documented—no prior auth required if diagnosis is present. (4) HCPCS C9759 (Mercator Bullfrog micro-infusion device) is NOT COVERED—deny all claims with this code. (5) Update claim denial reason codes to reference CPB 0777 and link providers to CPB 1000 for Xipere criteria requirements. (6) Alert ophthalmology providers and surgery centers in writing of the new restrictions. Failure to implement these edits will result in inappropriate claim approvals, subsequent denials on appeal, and recoupment requests from Aetna.